YIJOM-3823; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2017.11.003, available online at https://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Three-dimensional changes R. S. Louro1, J. A. Calasans-Maia2,

C. T. Mattos3, D. Masterson4,
M. D. Calasans-Maia1, L. C. Maia5

to the upper airway after

1
Department of Oral Surgery, Fluminense
Federal University, Valonguinho, Niteroi, RJ,
Brazil; 2Department of Orthodontics,
Fluminense Federal University, Centro, Nova

maxillomandibular Friburgo, RJ, Brazil; 3Department of

Orthodontics, Fluminense Federal University,
Valonguinho, Niteroi, RJ, Brazil; 4Library, Rio

advancement with
de Janeiro Federal University, Cidade
Universitária, Rio de Janeiro, RJ, Brazil;
5
Department of Orthodontic and Paediatric
Dentistry, Rio de Janeiro Federal University,

counterclockwise rotation: Cidade Universitária, Rio de Janeiro, RJ,

Brazil

a systematic review and

meta-analysis
R. S. Louro, J. A. Calasans-Maia, C. T. Mattos, D. Masterson, M. D. Calasans-Maia,
L. C. Maia: Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis.
Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017 International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to evaluate the effect of counterclockwise (CCW)
rotation and maxillomandibular advancement (MMA) on the upper airway space
using three-dimensional images. An electronic search was performed in the
PubMed, Cochrane Library, Scopus, Virtual Health Library, Web of Science, and
OpenGrey databases (end date July 2016); a hand-search of primary study reference
lists was also conducted. The inclusion criteria encompassed computed tomography
evaluations of the upper airway spaces of adult patients undergoing orthognathic
surgery with CCW rotation and MMA. The articles were evaluated for risk of bias
with a tool for before-and-after studies. A meta-analysis was performed with the
mean differences using a random-effects model. Heterogeneity was assessed with
the Q-test and the I2 index. The meta-analysis revealed significant (P < 0.001)
increases in both the total airway volume (effect size of 6832 mm3 and confidence
interval of 5554–8109 mm3) and the minimum axial area (effect size of 92 mm2 and
confidence interval of 70–113 mm2). The heterogeneity was low in both Key words: upper airway; orthognathic sur-
comparisons (I2 = 38% and 7%, respectively). The technique of mandibular gery; systematic review; meta-analysis.
advancement with CCW rotation produced significant increases in the volumes and
areas of the upper airway spaces. Accepted for publication 10 November 2017

0901-5027/000001+08 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
YIJOM-3823; No of Pages 8

2 Louro et al.

The improvement of airway function dur-
ing the treatment of dentofacial deformi-
ties is one of the goals required to achieve
a good outcome. Research into the upper
airways is a leading topic of study for the
different medical professionals working in
the maxillofacial region, primarily due to
the association between morphological
and volumetric changes after surgical
treatments in this area.
Orthognathic surgery is performed to
correct bone and soft tissue discrepancies.
Maxillary and/or mandibular surgeries can
cause different changes in the upper air-
way area and the volume of the oral and
nasal cavities, depending on the magni-
tude and direction of the correction1–15.
One of the most important procedures
related to the improvement of airway vol-
ume is maxillomandibular advancement
(MMA), which can also influence quality
of life and the quality of sleep in many
patients16,17.
A recent technique in the performance
of MMA is counterclockwise (CCW) ro-
tation of the occlusal plane, which has
been used widely to improve the aesthetic
profile9,12,14. This technique enhances the
aesthetic profile of class II patients by
optimizing the advancement of pogonion,
leading to a natural and harmonic mor-
phology of the chin area. CCW rotation of
the occlusal plane associated with MMA
has been reported to provide better results
in terms of airway function compared with
MMA alone9,12,14; however no systematic
review has yet been reported in the liter-
ature on this specific type of surgery.
The evaluation of orthognathic surgery
outcomes has traditionally been based on
two-dimensional (2D) images, such as
cephalometric X-rays, but the representa-
tion of the airways and other three-dimen-
sional (3D) structures in 2D has its
limitations13,18–22. As an alternative, 3D

Table 1. The search strategy used for each database.

Database Search strategy
PubMed (((((((((((((((((((((Mandibular Advancement[MeSH Terms]) OR Mandibular Advancement[Title/Abstract]) OR
Orthognathic Surgical Procedures[MeSH Terms]) OR Orthognathic Surg*[Title/Abstract]) OR Maxillary Osteotomy
[MeSH Terms]) OR Maxillary Osteotomy[Title/Abstract]) OR Counterclockwise[Title/Abstract]) OR Counter-
clockwise[Title/Abstract]) OR Anti-clockwise[Title/Abstract]) OR Clockwise[Title/Abstract]) OR Jaw Surg*[Title/
Abstract]) OR Bimaxillary Surgery[Title/Abstract])))))))) AND (((((((((((((((((((Cone-Beam Computed Tomography
[MeSH Terms]) OR Cone-Beam Computed Tomography [Title/Abstract]) OR Imaging, Three-Dimensional[MeSH
Terms]) OR Three-Dimensional*[Title/Abstract]) OR CAT Scan X-Ray[Title/Abstract]) OR 3-D Imag*[Title/
Abstract]) OR Cone-Beam Computed Tomography[MeSH Terms]) OR CT Scan Cone-Beam*[Title/Abstract]) OR
Tomography Cone-Beam Computed[Title/Abstract]) OR CAT Scans Cone-Beam[Title/Abstract]) OR I-CAT[Title/
Abstract]) OR ICAT[Title/Abstract]) OR Tomography Cone-Beam Computerized[Title/Abstract]) OR CT Cone-
Beam[Title/Abstract]) OR Volume CT[Title/Abstract]) OR CT Volume[Title/Abstract]) OR CBCT[Title/Abstract])
OR Cone beam computed tomography[Title/Abstract]) OR Cone Beam CT*[Title/Abstract])))
Scopus (TITLE-ABS-KEY ((‘‘Mandibular Advancement’’ OR ‘‘Orthognathic Surgery’’ OR ‘‘Maxillary Osteotomy’’ OR
counterclockwise OR counter-clockwise OR anti-clockwise OR clockwise OR ‘‘Jaw Surgery’’ OR ‘‘Bimaxillary
Surgery’’))) AND ((TITLE-ABS-KEY ((‘‘Cone-Beam Computed Tomography’’ OR ‘‘Imaging Three-Dimensional’’
OR ‘‘CAT Scan X-Ray’’ OR 3-d OR 3d OR ‘‘Cone-Beam Computed Tomography’’ OR ‘‘CT Scan Cone-Beam’’ OR
cone-beam* OR ‘‘Tomography Cone-Beam Computed’’ OR ‘‘CAT Scans Cone-Beam’’))) OR (TITLE-ABS-KEY
((i-cat* OR icat* OR ‘‘Tomography Cone-Beam Computerized’’ OR ‘‘CT Cone-Beam’’ OR ‘‘Volume CT’’ OR ‘‘CT
Volume’’ OR cbct OR ‘‘Cone beam computed tomography’’ OR ‘‘Cone Beam CT’’))))
Web of Science ((‘‘Mandibular Advancement’’ OR ‘‘Orthognathic Surgery’’ OR ‘‘Maxillary Osteotomy’’ OR Counterclockwise OR
Counter-clockwise OR Anti-clockwise OR Clockwise OR ‘‘Jaw Surgery’’ OR ‘‘Bimaxillary Surgery’’)) AND Tópico:
((‘‘Cone-Beam Computed Tomography’’ OR ‘‘Imaging Three-Dimensional’’ OR ‘‘CAT Scan X-Ray’’ OR 3-d OR 3d
OR ‘‘Cone-Beam Computed Tomography’’ OR ‘‘CT Scan Cone-Beam’’ OR cone-beam* OR ‘‘Tomography Cone-
Beam Computed’’ OR ‘‘CAT Scans Cone-Beam’’ OR i-cat* OR icat* OR ‘‘Tomography Cone-Beam Computerized’’
OR ‘‘CT Cone-Beam’’ OR ‘‘Volume CT’’ OR ‘‘CT Volume’’ OR cbct OR ‘‘Cone beam computed tomography’’ OR
‘‘Cone Beam CT’’))
Virtual Health Library (tw:((tw:((mh:‘‘Mandibular Advancement’’ OR mandibular advancement OR mh:‘‘Orthognathic Surgical
Procedures’’ OR orthognathic surg* OR mh:‘‘Maxillary Osteotomy’’ OR maxillary osteotomy OR counterclockwise
OR counter-clockwise OR anti-clockwise OR clockwise OR jaw surg* OR bimaxillary surgery))))) AND (tw:((tw:
((mh:‘‘Cone-Beam Computed Tomography’’ OR cone-beam computed tomography OR mh:‘‘Imaging, Three-
Dimensional’’ OR three-dimensional* OR cat scan x-ray OR 3-d imag* OR ct scan cone-beam* OR tomography cone-
beam computed OR cat scans cone-beam OR i-cat OR icat OR tomography cone-beam computerized OR ct cone-beam
OR volume ct OR ct volume OR cbct OR cone beam computed tomography OR cone beam ct*))))) AND (instance:
‘‘regional’’) AND (db:(‘‘LILACS’’ OR ‘‘BBO’’ OR ‘‘IBECS’’))
Cochrane Library (((((((((((((((((((((Mandibular Advancement[MeSH Terms]) OR Mandibular Advancement[Title/Abstract]) OR
Orthognathic Surgical Procedures[MeSH Terms]) OR Orthognathic Surg*[Title/Abstract]) OR Maxillary Osteotomy
[MeSH Terms]) OR Maxillary Osteotomy[Title/Abstract]) OR Counterclockwise[Title/Abstract]) OR Counter-
clockwise[Title/Abstract]) OR Anti-clockwise[Title/Abstract]) OR Clockwise[Title/Abstract]) OR Jaw Surg*[Title/
Abstract]) OR Bimaxillary Surgery[Title/Abstract])))))))) AND (((((((((((((((((((Cone-Beam Computed Tomography
[MeSH Terms]) OR Cone-Beam Computed Tomography [Title/Abstract]) OR Imaging, Three-Dimensional[MeSH
Terms]) OR Three-Dimensional*[Title/Abstract]) OR CAT Scan X-Ray[Title/Abstract]) OR 3-D Imag*[Title/
Abstract]) OR Cone-Beam Computed Tomography[MeSH Terms]) OR CT Scan Cone-Beam*[Title/Abstract]) OR
Tomography Cone-Beam Computed[Title/Abstract]) OR CAT Scans Cone-Beam[Title/Abstract]) OR I-CAT[Title/
Abstract]) OR ICAT[Title/Abstract]) OR Tomography Cone-Beam Computerized[Title/Abstract]) OR CT Cone-
Beam[Title/Abstract]) OR Volume CT[Title/Abstract]) OR CT Volume[Title/Abstract]) OR CBCT[Title/Abstract])
OR Cone beam computed tomography[Title/Abstract]) OR Cone Beam CT*[Title/Abstract])))

Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
YIJOM-3823; No of Pages 8
techniques such as computed tomography
(CT) can provide useful quantitative and
qualitative information, although they also
have certain limitations.
The aim of this study was to perform a
systematic review to evaluate the effect of
CCW rotation and MMA on the upper
airway using cone beam computed tomog-
raphy (CBCT).
Materials and methods
This review is reported in accordance
with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses
(PRISMA) statement23,24. The review
protocol is registered in the PROSPERO
database (CRD42016042969; http://www.
crd.york.ac.uk/PROSPERO).
The available scientific literature was
searched in July 2016, and alerts were
received from the databases up until
March 2017. The search was performed
to identify articles reporting the effects of
IdenƟficaƟon
PubMed
(n = 1050)
Screening
Assessment
Quality
analysis
Meta-
Fig. 1. Flow diagram of the study selection process (MMA, maxillomandibular advancement; VHL, Virtual Health Library).
Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
Upper airway changes after MMA with CCW rotation
CCW rotation and MMA on the upper
airway space using CT analysis. A
detailed search was conducted in the fol-
lowing electronic databases: PubMed,
Cochrane Library, Scopus, Virtual Health
Library, Web of Science, and OpenGrey.
An additional manual search was per-
formed of the reference lists of all primary
studies to identify additional relevant pub-
lications; the related records linked to each
primary study in the PubMed database
were also considered. No restrictions were
placed on the publication date or language.
Specific search strategies were developed
for each database with the guidance of a
librarian (DM) with expertise in systematic
reviews (Table 1).
The eligibility criteria were based on a
research question, defined in the PICO
format, which was as follows: What are
the effects, in adult patients (P), of max-
illomandibular advancement with coun-
terclockwise rotation (I) compared to
baseline (C) on the upper airway spaces
Scopus Web of Cochrane
(n = 1037) Science (n = 73)
(n = 772)
Records aŌer duplicates removed
(n = 1739)
Records screened by Ɵtle
and abstract and selected
for full-text reading
(n = 22)
Studies included in the
qualitaƟve synthesis and
assessed for risk of bias
(n = 7)
Records included in the
meta-analysis
(n = 3)
3
(O) as analysed in three dimensions? The
inclusion criteria were as follows: evalua-
tion of adult patients submitted to CCW
rotation with MMA, with a comparison of
postoperative and baseline measurements
to identify changes in upper airway vol-
ume and minimum axial area. Only
images obtained from CBCT and retro-
spective and prospective clinical records
were included. The cases selected for this
study did not have to have a diagnosis of
obstructive sleep apnoea (OSA) or respi-
ratory dysfunction. The following records
were excluded: case reports, case series,
review articles, editorials, opinions, and
pilot studies.
After the exclusion of duplicate records,
two reviewers (RSL and JACM) indepen-
dently analysed the list of titles and
abstracts according to the eligibility crite-
ria. Disagreements between the reviewers
were resolved by means of a consensus
meeting and, when appropriate, consulta-
tion with a third reviewer (MDCM).
VHL
(n = 10)
1717 records excluded
(Not related to the quesƟon,
case reports, pilot studies,
editorials, leƩers, and literature
reviews)
15 records excluded
(MMA alone, MMA with
mandibular setback, clockwise
rotaƟon, does not menƟon the
surgery technique)
4 records excluded
(Three for a ‘fair’ quality
assessment and one for a lack
of informaƟon (aƩempts to
contact the authors were
unsuccessful))
YIJOM-3823; No of Pages 8

4 Louro et al.

After checking the full texts of the reviewers were resolved through discus- No sensitivity or subgroup analyses were
records that were selected for eligibility sion, and if needed, via consultation with a necessary.
and making a final decision, the reviewers third reviewer (MDCM).
analysed the articles for risk of bias based The records were classified according to
Results
on the quality assessment tool for before- the answers obtained in the quality assess-
and-after studies25,26. This quality assess- ment, and the following criteria were estab- The PRISMA flow diagram of the study
ment investigated the following nine lished: ‘good’ quality for those records with selection process is presented in Fig. 1. The
items: whether the study question or ob- 6 to 9 ‘yes’ answers, indicating a low risk of established search strategy retrieved 2942
jective was clearly stated; whether the bias; ‘fair’ quality for those articles with 3 to records. After excluding duplicate articles,
eligibility criteria were pre-specified and 5 ‘yes’ answers, indicating a high risk of 1739 records remained, of which 22 were
clearly described; whether the research bias; and ‘poor’ quality for those records selected for full text reading. Seven of these
participants were representative of the with 1–2 ‘yes’ answers, indicating either a fulfilled the eligibility criteria and were
population; whether all eligible partici- lack of information or uncertainty over the finally included7–9,12,14,15,27; these articles
pants who met the entry criteria were potential for bias. were assessed for risk of bias (Table 2).
enrolled; whether the intervention was A meta-analysis was performed with Among the seven selected records, four
clearly described and consistently deliv- Comprehensive Meta-Analysis software achieved a ‘good’ score9,12,14,27, three
ered; whether the outcome measures were (version 3.2; Biostat, Englewood, NJ, obtained a ‘fair’ score7,8,15, and none
pre-specified, clearly defined, valid, reli- USA). Only articles with a low risk of obtained a ‘poor’ score. Five studies did
able, and assessed consistently; whether bias (‘good’ score in the quality assess- not report clear eligibility criteria, only
the outcome evaluators were blinded; ment) were considered eligible for this four reported a sample size calculation,
whether the statistical methods were per- meta-analysis. The data extracted from three did not have a sample that was
formed to assess changes in the outcome the articles and entered into the software representative of the population, three
measures from before to after the inter- were the mean differences and standard did not clearly describe or consistently
vention and whether the P-values were deviations, or the pre- and postsurgical deliver the intervention, none of the stud-
provided for those changes; and whether mean values and standard deviations, for ies reported blinding of the examiners, and
the outcome measures were acquired sev- volume (mm3) and minimum axial area five did not report multiple measurements.
eral times before and after the interven- (mm2) changes. A random-effects model Information regarding the studies, pa-
tion. The data were extracted from the was used, and the heterogeneity was tients, surgeries, follow-up periods, images
selected records by two reviewers (RSL tested with the Q-statistic and the I2 index. and software used, measurements, statistical
and JACM); disagreements between the The results are presented in forest plots. analyses, and outcomes is given in Table 3.
Table 2. Results of the methodological quality (risk of bias) assessment.
Carvalho Miranda Gonçalves Butterfield Butterfield Zinser Raffaini and
et al., 20129 et al., 201514 et al., 201312 et al., 20157 et al., 20158 et al., 201315 Pisani, 201327
1. Was the study question or objective Yes Yes Yes Yes Yes Yes Yes
clearly stated?
2. Were eligibility/selection criteria for No Yes Yes No No No No
the study population pre-specified and
clearly described?
3. Were the participants in the study Yes Yes Yes No No No Yes
representative of those who would be
eligible for the test/service/intervention
in the general or clinical population of
interest?
4. Were all eligible participants that met Yes Yes Yes Yes Yes Yes Yes
the pre-specified entry criteria enrolled?
5. Was the test/service/intervention clearly No Yes Yes No No Yes Yes
described and delivered consistently
across the study population?
6. Were the outcome measures pre- Yes Yes Yes Yes Yes Yes Yes
specified, clearly defined, valid, reliable,
and assessed consistently across all study
participants?
7. Were the people assessing the outcomes No No No No No No No
blinded to the participants’ exposures/
interventions?
8. Did the statistical methods examine Yes Yes Yes Yes Yes Yes Yes
changes in outcome measures from
before to after the intervention? Were
statistical tests done that provided p-
values for the pre-to-post changes?
9. Were outcome measures of interest taken Yes No Yes No No No No
multiple times before the intervention and
multiple times after the intervention (i.e.,
did they use an interrupted time-series
design)?

Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
 YIJOM-3823; No of Pages 8
Table 3. Data extracted from the studies included.
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular

Type of Type of Patients Intervention

Author, year study image Software
Age range,
Number and sex years Type of surgery Follow-up
Carvalho et al., 20129 Retrosp. CBCT 11 M 19–57 15 CCW MMAa 15 days (T2) ImageJ (area CSA)
9F 3 CWa 6 months (T3) Dolphin Imaging 11.0 (volume)
2 MMA alonea
Miranda et al., 201514 Retrosp. CBCT 8M 16–64 CCW MMA 6 months Dolphin Imaging 11.5
15 F
12
Gonçalves et al., 2013 Retrosp. CT 5M 13–62 CCW MMA and TMJP 3–9 days (T2) Dolphin Imaging 11.0
23 F 6–19 months (T3)
Butterfield et al., 20157 Retrosp. CBCT, LC, PSG 13 M 18–65 10 CCW MMAa 2–49 months (CBCT, LC) Dolphin Imaging 11.7
2F 5 not clearly reported 1–29 months (PS)
8
Butterfield et al., 2015 Retrosp. CBCT, LC, PSG 12 OSA (10 M/2 F) 18–65 7 CCW MMAa 3–12 months Dolphin Imaging 11.7
12 Control (6 M/6 F) 17 not clearly reported
Zinser et al., 201315 Retrosp. Helical CT scan 10 M 25–63 CCW MMA 3–6 months ZIB-Amira
7F
27
Raffaini and Pisani, 2013 Retrosp. CBCT 10 F Mean 22 CCW MMA 6–12 months Dolphin Imaging 11.0

Measurements Outcomes
Author, year Statistics
Area (CSA) Volume Area (CSA) Volume
Carvalho A, MCI, B, Pog Total Increased T2–T1 and T3–T1 Increased T2–T1 and T3–T1 Wilcoxon test: immediate and late postoperative period
et al., 20129 Decreased T3–T2 Decreased T3–T2 Student t-test: comparison between T1 (preop.), T2, and T3
Miranda SA, MAA Total Increased SA (P = 0.00045) and Increased (P = 0.00001) Student t-test or Wilcoxon test: compared samples in the preoperative
et al., 201514 MAA (P = 0.00055) and postoperative stages

Upper airway changes after MMA with CCW rotation

Gonçalves UAL, S–Epig, LAT, AP, Total SA, MAA, LAT, and AP increased Increased T2–T1 and Paired t-tests were performed to compare T2–T1, T3–T2, and T3–T1
et al., 201312 LAT/AP, VOL, SA, MAA T3–T1 and T2–T1 (P = 0.0001) T3–T1 (P = 0.001) Pearson product moment used to correlate alterations in
UAL and LAT/AP decreased cephalometric measurements and oropharyngeal airway space
T2–T1 (P = 0.001) changes
UAL decreased T3–T1
S–Epig increased T2–T1 with
significant decrease T3–T2
Butterfield AIH, ESS, %REM, AI, AL, Total Increased T2–T1 (P = 0.002) Increased T2–T1 Paired t-tests were performed to compare T2–T1
et al., 20157 AP, LAT, minCSA, PAS (P = 0.015)
Butterfield MPA, OPA, N–A, N–B, N– Total Increased T2–T1 (P = 0.001) Increased T2–T1 Paired t-tests were performed to compare T2–T1
et al., 20158 Pg, PAS, AL, AI, minCSA, (P = 0.05)
LAT, AP, LAT/AP
Zinser et al., SA, L, CSA, LAT, AP, Segmental Increased (NP, OP, Increased (NC P = 0.005, Wilcoxon test: comparison between T1 (preop.) and T2 (postop.)
201315 LAT/AP (NC, NP, and HP, P = 0.005) NP P = 0.003, OP P = 0.005,
OP, and HP) and HP P = 0.005)
Raffaini and SA, MAA Total Increased SA (average 34%) Increased (average 56%) Student t-test: comparison between T1 (preop.) and T2 (postop.)
Pisani, 201327 and MAA (average 112%)
A, A-point; AI, airway index; AIH, apnoea–hypopnoea index; AL, airway length; AP, anteroposterior dimension of the retroglossal airway; AP, anteroposterior dimension of the minCSA; B, B-point;
CBCT, cone beam computed tomography; CCW, counterclockwise rotation; CSA, cross-sectional area; CW, clockwise; CT, computed tomography; ESS, Epworth sleepiness score; F, female; HP,
hypopharynx; L, length; LAT, lateral dimension of the retroglossal airway; LAT, lateral dimension of the minCSA; LAT/AP, ratio of the lateral to the anteroposterior dimensions; LC, lateral
cephalogram; M, male; MAA, minimum axial area; MCI, maxillary central incisor; minCSA, narrowest airway cross-sectional area; MMA, maxillomandibular advancement; MPA, mandibular plane
angle; N–A, maxillary protrusion; N–B, mandibular protrusion; NC, nasal cavity; NP, nasopharynx; N–Pg, chin protrusion; OP, oropharynx; OPA, occlusal plane angle; OSA, obstructive sleep apnoea
; PAS, volume of the oropharynx and nasopharynx; Pog, pogonion point; PSG, polysomnogram; %REM, percentage of sleep spent in rapid eye movement; Retrosp., retrospective; SA, surface area; S–
Epig, sella to epiglottis distance; TMJP, temporomandibular joint prosthesis; UAL, upper airway length; VOL, volume.
a
Cases not used due to a lack of information; attempts to contact the authors were unsuccessful.

5
YIJOM-3823; No of Pages 8

6 Louro et al.

Fig. 2. Comparison of changes in total airway volume (in cubic millimetres) in maxillomandibular advancement with counterclockwise rotation.

All four studies categorized as ‘good’ in
terms of the risk of bias used computed
tomography, with three using CBCT scans
and one using CT scans. Three studies used
CCW rotation with MMA and reported clear
results from the separate groups, allowing
the data to be extracted. Only one study
presented more than one type of surgery;
data were not collected from this study9.
Of the four records with satisfactory
quality assessments, one was excluded
from the meta-analysis because it was
not possible to extract the appropriate data
and attempts at contacting the authors to
provide the data were unsuccessful9.
Therefore, three records were used for
the meta-analysis12,14,27.
Three studies, reporting the results for a
total of 56 patients, were included in the
two comparisons, i.e., volume and mini-
mum axial area. The meta-analysis
revealed a significant (P < 0.001) increase
in the magnitude of the total airway vol-
ume (Fig. 2), with an average effect size of
6832 mm3 and a confidence interval of
5554–8109 mm3; this was the primary
outcome. The heterogeneity was low (P-
value of 0.195 for the Q-test and
I2 = 38.8%). A significant (P < 0.001) in-
crease was also demonstrated for the sec-
ondary outcome, i.e., the minimum axial
area (Fig. 3). The effect size was 92 mm2
with a confidence interval of 70–113 mm2,
and the heterogeneity was very low (P-
value of 0.341 for the Q-test and I2 = 7%).
Discussion
Three-dimensional analysis of the upper
airways is a reliable method used by health
professionals13,28–33. There are numerous
3D methods to assess the effects of orthog-
nathic surgery on the airways, such as
those detailed in the works of Miranda
et al.14 and Gonçalves et al.12. CT33 and
magnetic resonance imaging (MRI)13,29
are known to be the most common tech-
niques used by professionals, and these
techniques allow the assessment of the
minimum axial area and volume of the
upper airway. Both are considered reli-
able, but MRI is expensive, is less fre-
quently available, and the patient must be
lying down during the examination. With
regard to the latter point, when the patient
is placed in this position, it is difficult to
accurately establish centric relation,
which must be determined to formulate
an appropriate treatment plan for orthog-
nathic patients. Most dental tomographies
are performed with the patient sitting and
in centric occlusion. Due to these facts,
and because of the reliable and widespread
use of CT in dentistry, the articles included
in this systematic review and meta-analy-
sis were required to present their results as
measured with CBCT.
The ideal study type for inclusion in a
systematic review would be the random-
ized clinical trial (RCT). However, there
are ethical aspects that limit this type of
study design for surgery patients, includ-

Fig. 3. Comparison of changes in minimum axial area (in square millimetres) in maxillomandibular advancement with counterclockwise rotation.

Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
YIJOM-3823; No of Pages 8
ing the following: blinding is not feasible
for patients and professionals due to the
nature of the procedures; the surgical tech-
nique cannot be randomized because the
patient must have the best treatment op-
tion. Non-randomized clinical studies
were selected for this review, and all of
them were retrospective studies (n = 7). A
before-and-after quality assessment was
used (http://www.nhlbi.nih.gov/
health-pro/guidelines/in-develop/
cardiovascular-risk-reduction/tools/
before-after)25,26. The before-and-after
quality assessment is a useful method
for comparing the effects of a procedure
to the baseline values of the outcome
assessed. The studies included were clas-
sified as having a good score in the quality
assessment, considering the methodology
of before-and-after studies. However,
these studies provided lower scientific
evidence than would have been provided
by RCTs, because there was no randomi-
zation or blinding. This could be consid-
ered a limitation of this review. The
quality assessment was performed to ob-
tain the best evidence available on the
subject.
Surgeons are aware that the dimensions
of the upper airway will change following
orthognathic surgery and these changes
could alter the treatment plan. MMA
improves the total airway volume and
improves the volume of the retropalatal
and retrolingual regions16. Numerous
studies have demonstrated the same
results for minimum cross-sectional area
and total volume3,20. These findings may
optimize the respiratory function postop-
erative; however, it is recommended that
polysomnography (PSG) be performed in
patients with OSA to correctly assess this
improvement.
Over the last decade, surgical manipu-
lation of the occlusal plane to enhance
facial harmony has been performed wide-
ly34. The occlusal plane can be changed by
clockwise or CCW rotation, and this will
affect different aspects of the airway mor-
phology9. No studies have compared
MMA alone to CCW rotation + MMA in
order to determine whether the association
of these two procedures really optimizes
the results of MMA alone; however, some
authors have suggested this notion in their
papers9,12,14. CCW rotation with MMA
could optimize the gain in airway space
due to the more inferior and anterior posi-
tioning of the bone and soft tissues with
this procedure. There is evidence to con-
firm that MMA improves airway dimen-
sions1,3,4,7,10,15,16,19,28,30, but there is little
evidence that the association of this tech-
Please cite this article in press as: Louro RS, et al. Three-dimensional changes to the upper airway after maxillomandibular
advancement with counterclockwise rotation: a systematic review and meta-analysis, Int J Oral Maxillofac Surg (2017), https://doi.
Upper airway changes after MMA with CCW rotation
nique with CCW rotation will enhance the
gain12,14,27.
Significant increases in the magnitude
of the total airway volume and the mini-
mum axial area were observed in the meta-
analysis. Similar results were found in a
meta-analysis of MMA alone16, which
reported a total volume increase that
was very similar to that found in the
present study. The authors of the afore-
mentioned meta-analysis16 compared
MMA alone1,30 and MMA together with
CCW rotation, in the same group
patients27. This is an important limitation
of the present review, because numerous
authors7,8,9,16 did not differentiate be-
tween these two methods (i.e., MMA
alone and CCW rotation + MMA). Other
studies have demonstrated good results for
MMA alone5,28, but the results were worse
than those found for the association of
CCW rotation and MMA found in the
studies included in the present review.
The minimum axial area is an important
value for airway function. According to
Schendel et al.30, there is an association
between the minimum axial area and the
occurrence of OSA. Consequently, an in-
crease in this value after treatment is a
good outcome in orthognathic patients. An
important increase in this value was found
in the present meta-analysis. This review
found evidence to infer that MMA + CCW
rotation of the occlusal plane increases the
volume and minimum axial area values.
However, clinical studies (RCTs) compar-
ing MMA alone to MMA + CCW rotation
are required to obtain scientific evidence
for use in clinical decision-making. The
greatest difficulty faced in this study was
the scarcity of the literature comparing
these two techniques.
Funding
None.
Competing interests
None.
Ethical approval
Not applicable.
Patient consent
Not applicable.
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Address:
Jose Albuquerque Calasans Maia
Faculdade de Odontologia
Universidade Federal Fluminense
Rua Mario Santos Braga 28 – terceiro andar
Centro
Niteroi
RJ CEP 24020-140
Brazil
E-mail: josecalasans@id.uff.br